Alcohol-Use Disorder and Severe Mental Illness.

Alcohol-use disorders (AUD's) commonly occur in people with other severe mental illnesses, such as schizophrenia or bipolar disorder, and can exacerbate their psychiatric, medical, and family problems. Therefore, to improve detection of alcohol-related problems, establish correct AUD diagnoses, and develop appropriate treatment plans, it is important to thoroughly assess severely mentally ill patients for alcohol and other drug abuse. Several recent studies have indicated that integrated treatment approaches that combine AUD and mental health interventions in comprehensive, long-term, and stagewise programs may be most effective for these clients.

A lcoholuse disorder 1 (AUD) is ment as AUD, the information summa of people with bipolar disorder also the most common cooccurring rized in this article pertains to the met the lifetime criteria for an AUD disorder in people with severe broader problem area of alcohol and diagnosis, compared with 16.7 percent mental illnesses, such as schizophrenia other drug (AOD)use disorders among of people in the general population and bipolar disorder. This article re people with severe psychiatric disorders. (Regier et al. 1990). Furthermore, ac views several aspects of AUD among cording to the National Comorbidity mentally ill patients-prevalence and Study, people with mania are 9.7 etiology, clinical correlates, course and PREVALENCE AND ETIOLOGY times as likely as the general population to meet the lifetime criteria for alcohol outcome, assessment, and treatment-Severe mental disorders frequently are dependence (Kessler et al. 1996). emphasizing practical clinical impli complicated by comorbid disorders, Because of the ways in which AOD cations within each of these categories. such as medical illnesses, mental retar use disorders complicate severe mental Because people with AUD also fre dation, and AOD abuse. Cooccurring illness, comorbidity rates tend to be quently suffer from other druguse dis AODuse disorders represent the most particularly high among young males orders with similar clinical correlates, frequent and clinically most significant and clients in highrisk settings, such similar impacts on the course of mental comorbidity among mentally ill pa as hospitals, emergency rooms, and illnesses, and similar principles of treat tients, and alcohol is the most com homeless shelters. The high rates of monly abused drug (Cuffel 1996).
AODuse disorders, especially among 1 The term "alcoholuse disorder" used in this arti Undoubtedly, the fact that alcohol is young adults, may be due partly to cle encompasses alcohol abuse and dependence readily available and that its purchase changes in the United States' mental as defined in the American Psychiatric Associa and consumption are legal for anyone health care system during the past few tion's Diagnostic and Statistical Manual of age 21 and older contributes to its wide decades. An entire generation of peo phreniform disorder and 42.6 percent received few vocational, recreational, and social opportunities but experienced regular exposure and ready access to AOD's. As a result, the rates of diag nosed AODuse disorders in mental health settings have continued to rise. In addition, clinicians have become more aware of the high prevalence of AODuse disorders and more skilled at identifying them (Cuffel 1996).
Although people with severe mental illnesses probably experiment with AOD's for the same reasons as other members of the general population, sev eral additional factors may contribute to the elevated rates of AODuse disor ders among severely mentally ill peo ple. These factors include a downward social drift into poor, urban living set tings, resulting in increased exposure and access to AOD's; attempts to alle viate, or selfmedicate, the symptoms of mental illness, the side effects of psy chotropic medications, and the dyspho ria associated with mental illness; and attempts to avoid being labeled a "men tal patient" (Minkoff and Drake 1991 ing mechanisms (i.e., the etiology) of AODuse disorders for this population may include early experimentation due to social pressure; desire to experience alcohol's shortterm effects, such as re lief of anxiety; and clinical correlates, such as antisocial behavior.
Although more research must be conducted on the etiology of AODuse disorders in mentally ill people, most likely these disorders are determined, as in other people, by a complex set of biological, psychological, and social (i.e., biopsychosocial) factors. How ever, distinguishing the causes of AOD use disorders from factors that sustain AOD use or that are correlates or con sequences of AOD use often is difficult. For example, the following items appear to be related to sustained AUD, regard less of the reasons for initial alcohol use: positive reinforcement in the brain's reward system; association with internal or external cues through classi cal conditioning; poor cognitive, social, and vocational functioning; and lack of significant social and material re sources (Donovan 1988).

SOCIAL AND PSYCHOLOGICAL CORRELATES OF AUD
Several studies have indicated that AUD among people with severe mental ill nesses is associated with various mani festations of poor psychological and social adjustment (Dixon et al. 1990;Drake et al. 1989;KozaricKovacic et al. 1995). These manifestations include relapses of psychiatric symptoms; psy chosocial instability; other druguse disorders; disruptive behavior; medical problems, such as HIV infection; family problems (e.g., in managing finances or maintaining positive relationships with family members); and institutional ization in hospitals and jails. Moreover, patients with dual diagnoses of severe mental illness and AUD are particularly prone to unstable housing arrangements and homelessness (see sidebar, pp. 90-91). Finally, dually diagnosed patients tend to be noncompliant with outpa tient treatment and frequently receive health services in emergency rooms, hospitals, and jails (Bartels et al. 1993).
Not all these correlates, however, have been observed consistently (e.g., the exacerbation of schizophrenic symp toms), and some correlates (e.g., vio lence or HIV infection) may be linked more closely with the abuse of drugs other than alcohol.
Although one is tempted to regard AUD as the cause of the above mentioned social and psychological problems, many additional factors may contribute to poor adjustment. For ex ample, alcoholabusing patients with mental disorders also are prone to abuse other potentially more toxic drugs, to be noncompliant with medications, and to live in stressful circumstances without strong support networks (Drake et al. 1989). Moreover, these patients may differ premorbidly from patients with the same mental disorders who do not abuse drugs. Laboratory experiments may help clarify some of the relation ships between AUD and poor adjust ment, but the circumstances, quality, and quantity of alcohol use in a labora tory may differ significantly from the typical alcoholuse patterns of people in the community (Dixon et al. 1990). Support for the role of AUD in causing poor adjustment, however, comes from findings indicating that severely men tally ill patients who become abstinent show many signs of improved well being. These patients either resemble severely mentally ill people who have never experienced AUD (Drake et al. 1996a) or rate between nonAOD users and current users on many clinical and functional measures (Kovasznay 1991;Ries et al. 1994).

COURSE AND OUTCOME
Data regarding the course and outcome of cooccurring mental illness and AUD are accumulating rapidly. Shortterm studies (i.e., those lasting 1 year or less) of patients in traditional treatment systems indicate that these dually diag nosed people are prone to negative outcomes, such as continuing AUD, as well as to high rates of homeless ness, disruptive behavior, psychiatric hospitalization, and incarceration. For example, outpatients with schizophre nia and cooccurring AUD had twice the rate of hospitalization during 1year followup compared with patients with only schizophrenia (Drake et al. 1989). Fewer studies have been conducted on the longterm outcomes (i.e., results more than 1 year later), but findings tend to show persistent AUD and poor adjustment (Drake et al. 1996a;KozaricKovacic et al. 1995).
Conversely, dually diagnosed pa tients who achieve abstinence appear to experience better prognoses and more positive adjustment, including improved psychiatric symptoms and decreased rates of hospitalization. For example, ECA study participants with schizo phrenia and AUD who attained absti nence had decreased rates of depression and hospitalization at 1year followup (Cuffel 1996). These optimistic find ings have fueled attempts to develop more effective AUD interventions among psychiatric patients (see the section "Treatment").

ASSESSMENT
Thorough AODuse assessment in cludes three overlapping but con ceptually separable tasks: detection, diagnosis, and treatment planning (Drake et al. 1996b). Detection refers to the identification of harmful or dan gerous alcoholuse patterns, whether or not they fulfill the criteria of abuse or dependence. Conversely, diagnosis denotes the assignment of a label of AODuse disorder, based on the criteria of the American Psychiatric Associ ation's Diagnostic and Statistical Manual of Mental Disorders (DSM). Treatment planning entails a more thor ough analysis of the biopsychosocial factors sustaining AOD abuse and a specific plan to address them.

Detection
Numerous studies have shown that AODuse disorders typically are un derdiagnosed in acutecare psychiatric settings (Drake et al. 1993a). Several factors account for the high rates of nondetection, including mental health clinicians' inattention to AOD abuse; patients' denial, minimization, or in ability to perceive the relationships be tween AOD use and their medical and social problems; and the lack of reliable and valid detection methods for this population. Failure to detect AOD abuse in psychiatric settings can result in mis diagnosis; overtreatment of psychiatric syndromes with medications; neglect of appropriate interventions, such as detoxification, AOD education, and AOD abuse counseling; and inappro priate treatment planning.
Several procedures could improve the detection of AODuse disorders and of potentially harmful AOD use among psychiatric patients. For exam ple, mental health clinicians should be educated about AOD's and, subse quently, should maintain both a high index of suspicion for AODuse dis orders and an awareness of their clini cal correlates. Little evidence exists indicating that psychiatric patients can sustain moderate AOD use over long periods of time without incur ring problems (Drake et al. 1996a), although AOD use without abuse may occur at any time (Lehman et al. 1996). Consequently, clinicians should pay attention to any current AOD use, even if there appear to be no harmful conse quences. Furthermore, clinicians should pay attention to reports of clients' past AODrelated problems, because the clients are more likely to report past use than current use (Barry et al. 1995).
Multiple tools are available that detect the majority of mentally ill peo ple who abuse alcohol. These tools in clude brief screening tests, such as the CAGE and the Michigan Alcoholism Screening Test (MAST). Other standard detection approaches include assessment using more than one type of information (e.g., patient selfreports combined with laboratory tests) and information from multiple sources (e.g., family members or friends) (Drake et al. 1993a). In addition, Rosenberg and colleagues (1996) recently developed a screening instrument, the Dartmouth Assessment of Lifestyle Instrument, that detects AODuse disorders in psy chiatric patients with greater accuracy than other instruments.

Diagnosis
According to the DSM criteria, persis tent alcohol use resulting in social, vocational, psychological, or physical problems should be considered abuse or dependence. This definition has sev eral implications for diagnosing AOD use disorders in severely mentally ill patients. For example, in psychiatric patients, who are more vulnerable to the effects of psychoactive drugs, use of relatively small amounts of AOD's may result in psychological problems or relapse of the symptoms of mental illness or may evolve into an obvious use disorder (Dixon et al. 1990;Drake et al. 1989). Moreover, clinicians must be aware that in many patients with apparent dual diagnoses, AOD use may have induced the second psychiatric disorder (Lehman et al. 1994).

Treatment Planning
During treatment planning, the clini cian, together with the patient, reviews all data and specifies a strategy for further exploration or change of AOD use behavior. Treatment planning includes a thorough biopsychosocial evaluation encompassing the follow ing areas (Donovan 1988

HOMELESSNESS AND DUAL DIAGNOSIS
Homeless people with cooccurring severe mental illnesses and alcohol use disorder (AUD) represent a particularly vulnerable subgroup of the homeless with complex service needs (Drake et al. 1991). Although often referred to as dually diagnosed, these people typically are impaired by several additional problems, in cluding abuse of drugs other than alcohol, general medical illnesses, and legal problems. This group also has histories of trauma and behav ioral disorders, deficient social and vocational skills, and support net works that include people involved in alcohol and other drug (AOD) abuse or other illegal behavior. Compared with other homeless subgroups, those with cooccurring severe mental illnesses and AUD are more likely to experience harsh living conditions, such as living on the streets rather than in shelters; suffer from psychological distress and demoralization; grant sexual favors for food and money; be picked up by police; become incarcerated; be isolated from their families; and be victimized (Fischer 1990). Much of our current knowledge of homeless adults with dual disor ders comes from National Institute on Alcohol Abuse and Alcoholism initiatives funded by the Stewart B.
McKinney Act (Huebner et al. 1993). These initiatives include a 3year, 14project demonstration to develop, implement, and evaluate interventions for homeless adults with AODrelated problems. Two of the projects specifically have targeted homeless people with co occurring severe mental illnesses and AODuse disorders.

Prevalence and Etiology
In a comprehensive review, Fischer (1990) found that between 3.6 and 26 percent of homeless adults suf fered from both a mental disorder and AUD. The rates of cooccurring mental and AODuse disorders ranged from 8 to 31 percent. Other recent reviews also have determined that the rates of dual diagnoses among the homeless range from 10 to 20 percent (Drake et al. 1991).
Many studies investigating the causes (i.e., etiology) of homelessness and dual diagnoses have suggested that people with cooccurring mental and AODuse disorders are particu larly prone to losing family supports and stable housing and becoming homeless (Drake et al. 1991). One reason for this increased risk appears to be that dually diagnosed clients often are excluded from housing and treatment programs designated specifically for people with single disorders (Drake et al. 1991).

Management of Homeless People With Dual Diagnoses
Several consistent themes have emerged in the literature on inter ventions for homeless people with dual disorders. Most important, in terventions should focus primarily on meeting the clients' basic needs related to subsistence and safety. Moreover, appropriate interventions should provide needed structure, support, and protection. Specific treatment recommendations include the following (Drake et al. 1991 Recent studies have examined the integration of mental health, Thus, treatment planning is a con tinuous, dynamic, and longterm pro cess based on the clinician's and patient's collaboration.

TREATMENT
For historical reasons, the mental health and AODabuse treatment systems in the United States are quite separate. De spite attempts to link the two treatment systems in traditional approaches to the care of patients with dual diagnoses, poor coordination between the systems may act as a treatment barrier for these patients (Osher and Drake 1996;Ridgely et al. 1987).
Over the past 15 years, however, mental health programs serving peo ple with severe mental illnesses have moved toward integrating AODabuse treatment into a comprehensive treat ment approach in which the same clini cians or teams of clinicians combine both mental health and AODabuse philosophies and treatment components (Carey 1996;Drake et al. 1993b;Drake and Mueser 1996;Minkoff and Drake 1991). In addition to integrating mental health and AODabuse treatments, many of these programs also incorporate inten sive case management approaches and outreach to facilitate engagement in treatment; comprehensive services and a team orientation; various types of group interventions; and a longitudinal, stagewise approach (Mueser and Noordsy 1996). A longitudinal, stage wise approach is based on the findings that the recovery process typically oc curs over years rather than weeks and often proceeds in several steps (e.g., the clients require motivational interven AOD abuse, and housing interven tions in various configurations. These studies show that both engag ing and retaining dually diagnosed homeless people in treatment pro grams are extremely difficult, espe cially in shortterm or residential programs (Blankertz and Cnaan 1994;Burnam et al. 1995;Rahav et al. 1995). Furthermore, any gains that the clients make during short term or residential treatment tend to erode rapidly following discharge. Several observations may help ex plain these findings. For example, behaviors that may represent com mon adaptations to homeless living, such as intimidating or threatening other people, often are incompati ble with participation in treatment and recovery programs (Weinberg and Koegel 1995). Homeless people also often have difficulty participat ing in treatment or rehabilitation before they have attained some meas ure of stable subsistence (Baxter and Hopper 1981). Finally, rehabil itation and recovery are longterm endeavors that take years for most dually diagnosed people. Conse quently, programs that first address the clients' subsistence needs and then provide longterm treatment in progressive stages are best suited for dually diagnosed homeless people (Drake et al. 1994).

Summary
Among the homeless, those with severe mental illnesses and co occurring AUD constitute a com plex subgroup. Meeting their needs requires an intensive effort over months or years, with multidisci plinary teams providing outreach; addressing subsistence needs; inte grating mental health, substance abuse, and housing interventions; and allowing for a longitudinal, stagewise recovery process. Because researchers have identified some of the pathways by which dually diag nosed individuals frequently become homeless, interventions to prevent homelessness also may be possible. Such preventive interventions could focus on unstable housing situations and evictions, more careful discharge planning from institutional settings, greater support for families, more efficient use of resources, and help with money management (Substance Abuse and Mental Health Services Administration 1996). WEINBERG, D., AND KOEGEL, P. Impediments to recovery in treatment programs for dually diag nosed homeless adults: An ethnographic analysis. Contemporary Drug Problems 22:193-236, 1995. tions before they are ready to participate in abstinenceoriented interventions). Osher and Kofoed (1989) concep tualized four overlapping stages of AOD treatment for patients with se vere mental illnesses: engagement, persuasion, active treatment, and re lapse prevention. Engagement includes developing a trusting relationship, or working alliance, with the patient, whereas persuasion entails helping the patient to perceive and acknowledge the adverse consequences of AOD use in his or her life and develop motivation for recovery. During active treatment, the clinician helps the patient achieve stable recovery in the form of either controlled use or, preferably, absti nence. Relapse prevention focuses on helping the patient maintain stable re covery. During each stage, a range of treatment options are available, and the specific treatment plan should re flect the patient's preferences. For ex ample, some patients may benefit from participating in selfhelp programs (e.g., Alcoholics Anonymous) during active treatment or relapse prevention, whereas other patients may not. Clini cians employing a stagewise treatment approach may find it useful to consult a growing number of clinical guides de scribing various strategies for integrat ing mental health and AOD treatments for patients with dual diagnoses (e.g., Daley and Thase 1994;Evans and Sullivan 1990;Gold and Slaby 1991;Miller 1994; as well as the articles cited in the preceding paragraph).
Most programs integrating mental health and AOD treatment provide services on a longterm, outpatient basis in the community and attempt to minimize the time spent in inpatient, detoxification, or residential settings.
Communitybased treatment is em phasized because skills acquired by severely mentally ill patients in one setting (e.g., in a clinic) often fail to generalize to other settings (e.g., every day life in the community). Thus, a premium is placed on working with patients in their natural environments. Nevertheless, brief treatment compo nents in inpatient and detoxification settings can provide valuable opportu nities for clinicians to establish or re establish therapeutic relationships with patients during the engagement stage and to motivate patients to examine their AOD use and its possible conse quences during the persuasion stage. Inpatient and outpatient services must be coordinated, however, in order to maximize longterm treatment gains.
Several recent studies indicate that integrated treatment programs combin ing AODabuse and mental health inter ventions within the same setting result in more positive outcomes than tradi tional, nonintegrated treatment systems (Drake et al. 1996a;Godley et al. 1994;Mueser et al. 1996). These studies show a steady reduction in AOD use, with the number of stably abstinent patients increasing with each year of consistent treatment. Other findings support the concept of treatment stages in the re covery process (McHugo et al. 1995). For example, in a recent study in New Hampshire, clients moved steadily through the stages of engagement, per suasion, active treatment, and relapse prevention, and approximately 50 per cent of them achieved abstinence after 3 years of treatment .
Not all investigators, however, have reported positive results of integrated treatment for dualdiagnosis patients. For example, Lehman and colleagues (1993) failed to find a beneficial effect of integrated treatment, possibly be cause the AODabuse measure they employed (i.e., the Addiction Severity Index) was not sufficiently sensitive to changes in AOD use in the severely mentally ill population studied (Corse et al. 1995). Also, not all integrated treatment approaches may be equally effective. Jerrell and Ridgely (1995) reported that an integrated treatment program with a focus on behavioral skills training reduced AOD abuse more effectively than a more traditional 12step approach or a case management approach. The accumulated evidence suggests that providing integrated mental health and AOD treatment to dually diagnosed patients improves outcome compared with traditional, nonintegrated approaches. More re search is needed, however, before defini tive conclusions about the effectiveness of integrated treatment can be reached.

SUMMARY
Approximately 50 percent of clients with severe mental illnesses, such as schizophrenia and bipolar disorder, who are in community mental health settings develop AODuse disorders during their lifetime. The rate probably is even greater among highrisk groups, such as young men with histories of violence or homelessness, and among patients in acutecare settings. AOD use disorders among severely mentally ill patients are correlated with poor con current adjustment in several domains and with adverse shortterm outcomes, including high rates of homelessness, hospitalization, and incarceration.
Clinicians often overlook AOD abuse among psychiatric patients. The use of standard screening and evalua tion procedures could, however, greatly improve detection and diagnosis of AODrelated problems as well as treat ment planning for this patient popula tion. AODabuse treatment should be provided in stages over the long term by dualdiagnosis experts. Current re search suggests that for patients with dual diagnoses, treatment approaches that integrate mental health and AOD treatment are particularly effective. ■